I don’t think there can any longer be any doubt that Emirates is plain wrong in sacking the pilots of the Airbus A340-500 who made the error that led to the near-catastrophe in Melbourne.
Australia’s ATSB investigation agency has revealed its initial findings today and they make crystal clear that the whole question of electronic flight bag (EFB) use, at the centre of the incident, is going to be extensively investigated. Rightly so, this is unquestionably an industry-wide issue.
More remarkably, it turns out that Emirates has just introduced the practice of using a second EFB/laptop as a check against the first! So their position now is that the incident crew committed an error grievous enough to merit sacking, but they’re worried that another crew might do the same thing.
So logically, if another crew makes the same error, but they catch it with the second laptop, then they should be sacked too for making the same error in the first place. And if they shouldn’t be sacked, then neither should the incident crew since they didn’t have the benefit of the second laptop.
Report and press conference highlights, with memorable pictures below. Emirates statement here.
Here’s what I think are the key points from the report and briefing by ATSB director of aviation safety investigation Julian Walsh.
The immediate cause of the incident is confirmed as being the inadvertent entry of the wrong take-off weight into the laptop – which Walsh specifically calls an electronic flight bag (EFB – and the resulting too-low thrust-settings and V speeds.
The results were predictably dire, with three tailstrikes on the runway and two further contacts in the grass beyond the stopway. The landing-gear struck a strobe light and the localiser as the aircraft finally lifted off.
Here are the ground contact marks marked 1-5.
And here’s the localiser anntena.
And some of the aircraft damage.
At today’s briefing, Walsh said that, although they were still investigating, the ATSB did not think fatigue was a factor. (Significant, since some Emirates pilots have been suggesting that fatigue is an ongoing issue at the airline.) He also robustly defended the use of reduced power / flex take-offs, telling the assembled media it was proven and standard practice in the industry.
The captain, who was pilot non-flying on the take-off, incidentally had 8,195 hours total and 1,978 on the A340 of which 1,372 were on the -500; and the first officer had 8,316 hours total with 612 on the A340, of which 425 were on the -500. They’d flown respectively 98.9 and 89.7 hours in the preceding 30 days.
Regarding the error Walsh said this: “What we need to understand, and is the difficult part, is how the system allowed that to happen. And this is going to be quite a complex thing, to look at the operating environment and what was going on in the cockpit at the time. What sort of environmental issues there were with noise and distractions – that’s where the hard work is.”
And he also said that, since the drafting of the report, Emirates had changed its procedure. “Emirates has advised the ATSB that although there are a number of layers that are required to provide physical cross-checks during these calculations, in the interests of prudence, and until the circumstances are better understood, they have introduced a further level of independent cross-checking through the use of a second laptop computer.”
So, now the ATSB is going to be investigating the following:
• human performance and organisational risk controls, including:
− data entry
− a review of similar accidents and incidents
− organisational risk controls
− systems and processes relating to performance calculations
• computer-based flight performance planning, including:
− the effectiveness of the human interface of computer based planning tools.
• reduced power takeoffs, including:
− the risks associated with reduced power takeoffs and how they are
− crew ability to reconcile aircraft performance with required takeoff
performance, and the associated decision making of the flight crew
− preventative methods, especially technological advancements.
And the agency says Emirates told it on 17 April that “the following areas were under review”.
• human factors – including review of current pre-departure, runway
performance calculation and cross-check procedures; to determine if
additional enhancement is feasible and desirable, with particular regard to
error tolerance and human factors issues.
• training – including review of the initial and recurrent training in relation to
mixed fleet flying and human factors.
• fleet technical and procedures – including introduction of a performance
calculation and verification system which will protect against single data
source entry error by allowing at least two independent calculations.
• hardware and software technology – including liaising with technology
providers regarding systems for detecting abnormal take-off performance.
You can read the whole report here, and listen to the press conference here.
And you can read about some of the things going on in Emirates here.